Community-based Methadone Maintenance Therapy:

Transcription

1 Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

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3 Preface This report has been prepared to present the best practice outcomes in the context of delivering community-level methadone maintenance therapy (MMT) services to prevent HIV among people who inject drugs (PWID) in the rural, mountainous community of Santikhiri located Mae Salong Nok sub-district, Mae Fah Luang district, Chiang Rai province. Methadone is a pharmacological agent used for the treatment of opioid dependence, either through detoxification or long-term maintenance. Evidence demonstrates that maintenance-oriented interventions yield better results than detoxification in terms of sustainably reducing illicit drug use and in terms of HIV prevention. Maintenance has also been associated with significant gains in client health and quality of life while reducing expenses associated with drug use and restoring family relationships. Effective methadone treatment programs have also been associated with lower risks of fatal and non-fatal overdose. In Thailand, though methadone has been available for more than 40 years, only 111 district- and provincial-level hospitals total of over a thousand hospitals nationwide currently offer this important service. Due to strict government regulations and restrictions as well as staffing shortages, many hospitals are hesitant to provide this service. As a result, many people who use drugs (PWUD) who require the treatment are unable to access the service. The MMT model in the Santikhiri community was established through collaboration between several sectors to meet the needs of people who use drugs living in remote hilltribe communities. Civil society representatives, including people peer workers, are leading the implementation of the Santikhiri model though national government regulations are strictly applied and enforced while local authorities participate and support every aspect of service delivery. Significant tasks have been delegated to O-zone project workers in order to address

4 personnel shortages with great success. O-zone and PSI Thailand Foundation hope that this report can be used as a best practice example highlighting effective civil society participation in the delivery of methadone in community settings and inspire others working in the field to strengthen such services through the meaningful participation and involvement of people who use drugs. O-zone Chiang Rai PSI Thailand Foundation Cover: Located at an altitude of more than 1,200m, Santikhiri village is home to approximately 2,700 people, the majority of whom are identified as ethnic minorities.

5 Acknowledgements The development of the MMT model in Santikhiri and this invaluable report would not be possible without the empowering movement led by local peers and people who use drugs, the dedication and sacrifice of the Chiang Rai O-zone project workers, and the courageous and unwavering support of key individuals and partner agencies, including Mr. Vorayan Bunarat, District Chief Officer; Ms. Pornpimon Saksoong, Mae Chan Hospital pharmacist 1 ; the Global Fund to Fight AIDS, Tuberculosis and Malaria for the funding; local community leaders; Chiang Rai Provincial Public Health Office; the Princess Mother National Institute on Drug Abuse Treatment; the National Health Security Office; the National AIDS Management Center (NAMc); the national Sub-committee on the Promotion and Protection of HIV and AIDS Rights operating under the National AIDS Committee; as well as media agencies which have all been sources of support and encouragement. We appreciate their determination, dedication, and sacrifices and acknowledge the value of our partnerships in developing options to improve the quality of life of people who use drugs. We would also like to acknowledge Ms. Apinan Suwannarach who translated the original Thai version into English as well as Mr. Pascal Tanguay for providing editorial support. We would like to thank Bulletin Co. Ltd. for the design and layout of the report. Ultimately, O-zone workers are hopeful that bringing attention to this innovative approach to methadone delivery will stimulate expansion of the model and provide a platform from which to strengthen relationships with clients families and communities to better meet their needs. Verapun Ngammee Lead Author 1 In 2003, K. Pornpimon Saksoong was awarded the National Rolleston Award by the Intrnational Haem Reduciton Association in recognition of the success of the Mae Chan Project, a methadone maintenance and community-based care programme in Northern Thailand, run by the Mae Chan Hospital. The project was established in 1997 and covers 11 Akha hill-tribe villages.

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7 Contents Preface Acknowledgements Acronyms Executive Summary 9 Design and development of the implementation model 12 Methadone service delivery milestones from Santikhiri village 18 Results and best practices 20 Early stages Later stages Treatment outcomes 25 Lessons learned and elements of success Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

8 8 Acronyms AIDS HIV ICAAP MMT NAMc NHSO PWID PWUD SAO UN Acquired immune deficiency syndrome Human immunodeficiency virus International Congress on AIDS in Asia and the Pacific Methadone maintenance therapy National AIDS Management Center National Health Security Office People who inject drugs People who use drugs Sub-district Administration United Nations

9 9 Executive Summary Methadone is a synthetic opioid that mimics the action of heroin and other opiate drugs and has thus been used by medical professionals to treat opioid dependence. In the context of drug dependence treatment, methadone has traditionally been used through short-term detoxification or long-term maintenance. According to scientific research and published evidence in Thailand and globally, methadone maintenance therapy (MMT) yields better results in terms of sustained behavior change related to illicit drug use, in terms of prevention of HIV and other blood-borne infections, and in terms of client satisfaction and quality of life. MMT is recognized by United Nations agencies as a priority intervention in the comprehensive package to prevent HIV among people who inject drugs and is a critical component of national responses to reduce drug-related harms. 2 The government of Thailand has acknowledged the critical role of methadone by approving the Kingdom s first national harm reduction policy in At present, methadone is included in Thailand s universal health insurance scheme as well as in the social security scheme. This means that people who can access the Thai universal health insurance and social security schemes are eligible for free methadone treatment both for detoxification and long-term maintenance. Santikhiri is a village in the Mae Salong Nok sub-district of Mae Fah Luang district in Chiang Rai province. The village is located near the summit of Mae Salong Mountain, fifty kilometers (and several hours drive) from the town of Mae Chan. People living in Santikhiri face a range of important challenges that negatively impact both on their health and on their capacity to access health care services in the community: illicit drugs are widely available in the area; the local population is composed of multiple 2 UNAIDS, UNODC and WHO Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

10 10 ethnic minorities who speak different languages; overall socio-economic status of the community is below the national average with high rates of unemployment; and transportation to Mae Chan where the closest hospital is located is costly and requires several hours. These and other conditions have facilitated initiation of illicit drugs, for example to alleviation of pains and treat illnesses, and as a result, many residents in Santikhiri have become dependent on opioids. In the past, community representatives and leaders intervened to provide support to people who had become dependent on drugs. However, these efforts have not improved the situation for the vast majority of people who use drugs given that most efforts were implemented with the ultimate objective of cessation of drug use and sustained abstinence. After many years of efforts, it appears that the community has now recognized that this approach has not been effective: the number of PWUD has not decreased and PWUD are unable or not ready to become completely abstinent. Meanwhile, local drug use practices have shifted from smoking to injecting, increasing health risks both for the individuals and for the community around them. The shift to injecting especially increases the risk of contracting and spreading HIV, hepatitis B and C, and other blood-borne infections. O-zone, a civil society organization working on illicit drug use in Chiang Rai province, together with representatives and volunteer PWUD from the community, met to design and develop an effective solution for community leaders, healthcare providers and other stakeholders consideration. As a result of a number of brainstorming sessions, stakeholders in the community started to agree that the past approach had not been effective and that there was a need to find a new approach for treatment of opioid dependence. Given that the majority of PWUD in Santikhiri use opium and heroin, both PWUD and community members were already familiar with methadone and O-zone representatives proposed to dispense methadone in Santikhiri community through the drop-in center located there. The proposal was received positively and a consensus rapidly grew to acknowledge that co-operation between various sectors PWUD, their family members, community leaders, health service providers, and the local government would be necessary to the success of the intervention. Key stakeholders also agreed that the new approach would need to be in line with the context of the problem, be friendly and non-stigmatizing to clients and be easy to access.

11 11 Bottles of methadone are prepared by the Mae Chan Hospital team and dispensed by the O-zone workers in Santikhiri. The treatment of drug dependence in the community is an approach which has been recognized by both academic and international organizations as effective and sustaining. MMT in Santikhiri community is considered a thought-provoking example to learn from in order to extend service accessibility for PWID in other areas. PSI Thailand Foundation Field Manager Despite the facilitation of a strong consensus, some components of the proposed approach were questioned and challenged. For example, there were divergent expectations about whether PWUD should immediately cease drug use completely, or whether the service should promote a gradual reduction of drug use and encourage long-term behavior change. Such expectations fuelled important discussions regarding implementation models: whether to use methadone as a form of detoxification as recommended by the community leaders and the local government, or as a long-term substitute as recommended by people who use drugs, health service providers, and O-zone workers. In the end, the long-term maintenance model was approved by community leaders and government officials. Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

12 12 Design and development of the implementation model Authorities have regularly targeted people who use drugs in Santikhiri for rehabilitation campaigns where compulsory detention in boot camp-style institutions often managed by law enforcement personnel passes for treatment. O-zone s clients in Chiang Rai and other provinces have regularly requested assistance to address important weaknesses in the current national response to drug dependence treatment. Indeed, both clients and O-zone representatives acknowledge that compulsory detention in the name treatment is not effective, cost-effective or safe. Given that cessation of drug use is characterized by debilitating withdrawal symptoms and intense cravings for opiates, international best practices in drug treatment recommend that opiate substitution medication such as methadone be provided to alleviate the physical and psychological symptoms. In combination with pharmacological assistance for the relief of physical conditions, medical attention from health care professionals, as well as knowledgeable personnel in this field are important components of successful drug dependence treatment. In Thailand, methadone treatment is currently only available in district- and province-level hospitals and at a few remote drug treatment centers. Travelling to methadone service outlets is generally challenging, time consuming and costly. Moreover, language barriers and service eligibility are issues O-zone clients have frequently encountered that further limit access to this important service. As a result, accessibility and continuity of methadone services remains an important challenge highlighted by key agencies. 3 In order to address the challenges identified and improve service access among people who use and inject drugs, O-zone workers collaborated with local authorities to develop a community-based methadone service delivery model to better meet the needs of clients. 3 Institute for Population and Social Research, Mahidol University Evaluation of HIV programmes among female sex workers, people who inject drugs, and men who have sex with men; Ngammee, V. & Tanguay, P CHAMPION-IDU - Innovations, best practices and lessons learned - Implementation of the national response to HIV among people who inject drugs in Thailand ; World Bank Harm Reduction Policies and Interventions for Injection Drug Users in Thailand.

13 13 Through various official and informal meetings, a proposal was presented by representatives of the affected community and O-zone team workers to community leaders, the local governor, sub-district hospital representatives, and the Mae Chan Hospital team: to initiate local methadone treatment services in the Santikhiri village; and ensure meaningful community participation and involvement. High-level representatives from the Mae Chan Hospital showed interest and offered technical support, management tools, assistance for comprehensive documentation, staff mentoring and training, as well as equipment, including methadone, to support O-zone s efforts. Community leaders and local government representatives also endorsed the proposal. Initially, a number of government stakeholders expected that methadone would be delivered through a detoxification model in order to achieve abstinence. However, PWID representatives and O-zone workers reminded community leaders and government authorities that such an approach had been widely used in the past with little to no positive results. O-zone also reminded authorities that detoxification reduced healthseeking behaviors among PWID and has been strongly associated with relapse and other health risk behaviors. Persistent differences of opinion led to intense discussions where each group acknowledged the inherent mutual dependence. During discussions, documentation and evidence were presented and reviewed in support of both approaches. Ultimately, community leaders and local government officials insisted on using the detoxification approach and argued that, despite challenges and past results, there was scope to improve and generate positive results. Support from community leaders and members was generated by regular meetings with the O-zone team as well as sustained community-level advocacy efforts. Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

14 14 The Santikhiri communitybased methadone project was initiated to meet the needs of clients and improve accessibility to methadone. Evaluation of the short-term detoxification services in the project s early phases showed poor results and the approach was amended to promote long-term maintenance. Close collaboration with health service providers, government agencies and civil society organizations contributed to consensus building and ensured effective implementation of project activities. People who use drugs have played a meaningful role in all stages of project design, implementation and evaluation. Regular debriefing meetings between the Mae Chan Hospital and O-zone teams enhances quality of services and ensures that implementation bottlenecks and challenges are quickly identified and addressed. In the spirit of collaboration, PWID representatives and O-zone workers accepted to pilot the service under a detoxification model in favor of moving the project forward and preserving effective working relationships with key stakeholders in the community. However, O-zone representatives negotiated a specific timeline for the pilot to include a comprehensive evaluation and, should the service be found to be ineffective, the detoxification approach would be changed with a long-term maintenance model. All parties involved in the discussions agreed on this condition and its implications. Before service delivery could be initiated, clear roles and responsibilities had to be defined for all parties and a consensus was developed to support implementation of the methadone delivery model. All parties also developed a strong consensus on the guiding principles underpinning the effort, notably to offer accessible, comprehensive, evidence-based services that meet client needs and respect their privacy and confidentiality and safeguard their safety and protect their security. All parties also agreed to develop comprehensive monitoring and evaluation systems and develop protocols to minimize the risk of diversion of methadone.

15 15 From the beginning, the community-based methadone delivery services involved the following stakeholders: SAO Chief Administrator, SAO members, sub-district headman and other community leaders Each of these key leaders and figures of authority played important roles in terms of attending the meetings, evaluating the past performance in the community, counseling and advising project workers, promoting the project, and reassuring people in the community. The leadership of the individuals who provided support has been instrumental in facilitating an effective roll out of the project activities. O-zone workers, many of who are people recovering from drug use and dependence, hold regular team meetings to support efforts in client recruitment, client satisfaction and referrals to other health services. O-zone Foundation O-zone, a Thai civil society organization, has been a recipient of the Global Fund to Fight AIDS, Tuberculosis and Malaria since 2009 and contributes to HIV prevention among people who inject drugs as well as the overall improvement in quality of life of all people who use drugs. O-zone s experience under the CHAMPION-IDU project 4 led to important innovations, best practices and lessons learned for the care and support of Thai people who use drugs. O-zone plays an essential role in strengthening competencies among harm reduction workers across Thailand. In Santikhiri, the O-zone team has been responsible for recruiting workers and clients, assisting in the daily provision of methadone treatment including in terms of client assessment, distribution of methadone, observation of clients after administration, as well as coordination among a range of local and national stakeholders to ensure smooth local operations. 4 Ngammee, V. & Tanguay, P CHAMPION-IDU - Innovations, best practices and lessons learned - Implementation of the national response to HIV among people who inject drugs in Thailand Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

16 16 The O-zone drop-in center in Santikhiri offers comprehensive harm reduction and social support services to over 100 people dependent on opiates. PWID representatives, peers and volunteers From the very first stages of project development, this group played a critical role in sharing their needs, lessons learned, and experiences of treatment, as well as proposing responses and mechanisms for effective treatment tailored to meet the needs of PWID. These insights were precious and informed all stakeholders who worked on the project. Most importantly, their insights and experiences were critical in making the methadone service delivery effective, in recruiting and supporting clients throughout the course of treatment, while also being actively involved in the day-to-day operations of service delivery, thereby effectively addressing the government s staffing gap in this particular sector. Peers and volunteers were also trained to promote the project as well as monitor and document activities. Mae Chan Hospital Methadone is classified as a Schedule II narcotic in Thailand, thereby restricting its use to medical treatment requiring professional supervision and oversight in order to ensure compliance with national and international requirements. In 2003, Mae Chan Hospital s work was recognized with the National Rolleston Award from the International Harm Reduction Association for their efforts in setting up a community-based methadone project in a hilltribe village in Chiang Rai province. Today, the Mae Chan Hospital plays an important role in the Santikhiri community-based methadone project by providing academic information

17 17 and technical support with reference to methadone treatment, training and developing skills of related project workers, assessing and diagnosing clients prior to treatment, determining the course of methadone treatment for each client, providing treatment and follow-up in regards to treatment results, preparing and titrating methadone doses, and controlling and managing stocks of methadone. PSI Thailand Foundation The PSI Thailand Foundation was the principal recipient of the Global Fund grant and spearheaded the CHAMPION-IDU project, a comprehensive national-level response to HIV among PWID between 2009 and In the Santikhiri methadone project, PSI Thailand managed the CHAMPION-IDU project, which allocated funding, and personnel while providing operational management support along with overall responsibility for follow-up, evaluation and documentation of results. Chiang Rai Provincial Health Office - Anti-drugs division The implementation of methadone services is a critical component of the comprehensive package of interventions that can prevent the spread of HIV and other blood-borne infections. Despite several decades of experiences with this medication, a community-based approach to methadone service delivery was a significant innovation in Thailand. The Chiang Rai Provincial Health Office is a local government agency mandated to facilitate local implementation of government health policies. In the Santikhiri methadone project, its representatives played a vital role in facilitating consensus and encouraging partnerships across sectors as well as in reviewing restrictions and conditions that constrained accessibility to methadone. The Provincial Health Office also worked to remove structural obstacles while ensuring adherence to national government requirements and sourcing additional funds to support and expand activities. Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

18 18 Methadone service delivery milestones from Santikhiri village - Brainstorming sessions were held with peers and PWID representatives to analyze current issues related to drug dependence treatment, design a community-based service delivery model, and develop a proposal. The initial proposal highlighted the need for community-based methadone services in Santikhiri village. - O-zone representatives presented the proposal to local authorities and received suggestions and recommendations towards a consensus regarding the way forward. An agreement was reached where methadone detoxification services would be initially piloted and evaluated with the understanding that poor results would lead to a change in operational models from short-term detoxification to long-term maintenance. - In February 2012, the methadone detoxification service was initiated at the Santikhiri drop-in center operated by O-zone, with support from Mae Chan Hospital staff. - In August 2012, a meeting was held with the civil society representatives, public health officers and local government officials to present the outcomes generated under the detoxification model. Results collected from client interviews showed little to no positive results. - In the weeks that followed, a new consensus was forged around the operationalization of a long-term methadone maintenance model in the Santikhiri village. - In September 2012, the Mae Chan Hospital team delivered a number of technical capacity building workshops, including on-the-job mentoring, to improve the O-zone workforce s technical and management competencies.

19 19 - In October 2012, methadone maintenance therapy was initiated in the community in collaboration with PWID representatives, civil society organizations, and public health agencies (Mae Chan Hospital, Chiang Rai Provincial Health Office s Anti-drugs division). - From January to October 2013, methadone was delivered in the Santikhiri village. In October 2013, project results were once again evaluated using project results, follow-up and interviews with clients and stakeholders as well as desk based publications. - Between March 2013 and September 2014, a cumulative total of 205 clients were enrolled in the service.society sector, public health agencies (Mae Chan Hospital, Chiang Rai Provincial Public Health Office anti-drug scheme). - From January to October 2013, treatment outcomes were evaluated using research methodology, follow-up and evaluation with clients and stakeholders. - From January to October 2013, treatment outcomes were evaluated using research methodology, follow-up and evaluation with clients and stakeholders. Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

20 20 Results and best practices Detoxification with methadone has been implemented in Thailand for more than 40 years. While the concept of maintenance with methadone had been recognized in the academic literature and is considered a best practice intervention according to international experts, Thailand s approach has promoted detoxification, with few sites offering genuine maintenance programs. Methadone maintenance therapy (MMT) yields better results in terms of sustained behavior change related to illicit drug use, in terms of prevention of HIV and other blood-borne infections, and in terms of client satisfaction and quality of life. MMT is recognized by United Nations agencies as a priority intervention in the comprehensive package to prevent HIV among people who inject drugs and is a critical component of national responses to reduce drug-related harms. 5 Community-based methadone services in Santikhiri were designed to facilitate access for those in need by overcoming critical logistical barriers. Though national government policies and guidelines have been amended in recent years to include and promote methadone maintenance therapy, health service providers continue to promote detoxification-based models and a minority of methadone outlets offer genuine maintenance. Out of over a thousand hospitals nationwide, methadone is only available in only 111 hospitals, or about ten percent of the Kingdom s hospitals. Approximately 3,000 of the 40,300 Thai PWID are currently receiving methadone treatment across Thailand and clients continue to report significant accessibility challenges. The O-zone team in Santikhiri offers comprehensive harm reduction and social support services to over 100 people dependent on opiates through outreach and drop-in centers. Representatives from the Mae Chan Hospital regularly visit the O-zone drop-in center to provide technical support and professional mentoring. 5 UNAIDS, UNODC and WHO Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users.

21 21 Early stages The multi-sectoral consensus locally established under the Santikhiri methadone project has been critical to its successful implementation. With support from a wide range of government and non-government offices and officials in addressing community concerns, encouraging tolerance and support, building capacity and knowledge, the pilot methadone project was considered an important innovation. In order to sustain the consensus and collaborative model, the following steps were taken: 1. Several formal and informal meetings were held to establish joint processes to empirically assess the situation, identify the issues to be addressed, prioritize needs and interventions, and explore solutions in which all sectors would have a role to play. 2. Collect and share relevant evidence and project results, including client feedback to be shared throughout discussions and negotiations. 3. Negotiations emphasized respectful discussion and acknowledged the value of experience and knowledge of all stakeholders. Discussions remained focused on building understanding and developing an enabling process rather than seeking a specific predetermined outcome. In this sense, O-zone representatives combined a range of process options, including formal and informal discussions, presenting academic and evidence-based information, inviting experts to share information and opinions, as well as arranging study visits for community representatives to visit other communities to examine and explore options by exchanging ideas with other community members. 4. Virtually all decisions were made jointly and transparently. When conclusions did not align with the original intended strategy based on client needs, compromises were made to allow progress. Follow-up and evaluation of project results were analyzed in order to address weaknesses in the original design. Such open processes contributed to effective and sustained collaboration and partnerships. 5. Transparency in operations and implementation also contributed to building confidence among community representatives in regards to O-zone s work. Regular meetings contributed to smooth operations and to avoiding technical and logistical bottlenecks. Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

22 22 6. Documentation of project results has been critical to facilitating consensus and collaboration between the various stakeholders and data regarding outcomes continues to be regularly shared across the project partners. Data has been used to inform and amend the project strategy in favor of a maintenance service model. Overview of the process to set up the community-based methadone maintenance project in Santikhirl Analyze the problem / needs Drug users, families, community share lessons from past experience Propose suggestions and needs Hold discussion with all relevant stakeholders Drug users / Civil Society sector Use evidence, not emotions Use suggestions as a means for collaboration Understand the interdependent relationships among workers Make plans / execute tasks jointly Conflict Manage operational tasks among conflicting opinions Accept and discuss differences in opinion Retain all differences in opinion in discussions as valid to ensure consensus reached by all parties Collaborate by conducting follow-up and evaluation to use as information and evidence of the hypothesis Evaluate Learn Together Conclude the early stage Discuss information obtained from service provision Draw conclusions jointly Review and revise problematic operation procedures that may have caused objectives to remain unmet

23 23 The O-zone Chiang Rai team regularly meets with local authorities to report results and share plans for upcoming activities to ensure effective coordination and collaboration. Later stages Though Thailand s network of methadone providers is significant, community-based methadone maintenance services represent an important local and international innovation that strengthens Thailand s leadership role in HIV prevention. The service implemented through the O-zone drop-in center in Santikhiri is the first of its kind in that it combines multi-sectoral collaboration, including civil society organizations and people who use drugs; it relies on peers and people who use drugs to operate a significant part of the service; the service now promotes and facilitates access to genuine methadone maintenance therapy; and the service is delivered in a remote rural mountainous community where opiate drug use is common. Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

24 24 Overview of roles and responsibilities among implementing agencies Community Peers/ volunteers - Share needs and ideas for appropriate treatment - Take part in publicizing the treatment - Track other users - Provide information to prepare PWID to receive treatment - Follow up and assist PWID after treatment as peers Ozone center - Develop skills and provide resources needed by volunteers and peers - Provide methadone treatment under the supervision of medical professionals from Mae Chan Hospital - Coordinate among involved parties and sectors Hospital - Assess and diagnose clients prior to treatment - Determine courses of methadone treatment for individual clients - Develop skills for officers and relevant volunteers - Provide treatment, control and manage drug storage - Follow-up on treatment plan

25 25 Treatment Outcomes This is a table showing methadone treatment outcomes from March 8 - May 25, 2012 (Methadone detoxification period). Admissions Arrests Employed Relapses Recoveries Deaths Male Female Male Female Male Female Male Female Male Female Male Female This table shows Methadone treatment from October 1, December 20, 2014 (MMT period) Methadone Treatment Clients MMT Clients Employed Arrests Left Community for Employment Deceased by other Medical conditions/ Accident Recovers Stop MMT Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female For families of clients, the Santikhiri methadone project has generated significant benefits. Clients and families report securing gainful employment and re-entering the workforce while reducing considerable expenses related to daily drug use. Family members also report better relationships and fewer conflicts with clients enrolled in the Santikhiri methadone maintenance project. All this contributes to clients feeling more supported and motivated to engage in daily family life. Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

26 26 The O-zone Chiang Rai team holds regular information sessions to raise awareness, strengthen knowledge and improve attitudes of community leaders and members in regards to drugs, HIV, and public health Since starting methadone, I have never returned to using opium, I never quarrel with my wife, and I am so glad I took it. It is many times better than opium. I now have some savings, my wife is happy and so is my child. I am happy, also, that I no longer use opium. Before, I barely had enough to eat, but now, I have enough. Before, my child could barely go to school because I had no money. No matter how much we had, it was never enough. One day, not long after I started methadone treatment, opium was still in my system and there were cops making arrests in the village. I dared not go out for my daily dose of methadone, so my wife went to get it for me. My wife is supporting me on the methadone treatment. Male client, age 38 I used to worry that if the methadone service in the community and the administration is not good, there might be more overdose cases. But for the past two years, we found no overdose cases among clients of this service. This reflects good administration. People who use drugs are well-informed and are more aware of the risks associated with their drug use. O-zone field worker

27 27 My wife and kid are glad that I am not using drugs any longer. We have enough money. When we make THB 500, we were able to save some. Now, I have some savings, and am not taking any drugs. Previously, my child was never interested in where I went. Wherever I go, she never wanted to go. But now she joins me every day. I don t know how life would be without methadone. Now I don t have any more headaches or leg pain. Male client, age 48 The Santikhiri communitybased methadone project has generated significant results since its initiation in 2012 for clients, their families and local communities. By locating methadone services in the community and involving peers, this unique project has stimulated demand and attracted new clients thereby contributing to the achievement of national HIV prevention and drug control objectives. National authorities and Thai media have acknowledged the peer-led community-based methadone maintenance project in Santikhiri for being effective, cost-effective, safe, meeting client needs and aligned with national objectives. The benefits are not limited to the clients and their families the Santikhiri methadone maintenance project has yielded important positive results that benefit the community as a whole, including: Reducing drug use in the community Reducing the number of burglaries in the community Reducing the number of petty drug dealers in the community Reducing stigma and discrimination against people who use drugs in the community Foster an enabling environment where people who use drugs are less fearful of accessing health care services Increasing meaningful participation and gainful employment of people who use drugs Increasing community awareness and skills regarding management of drug use and dependence Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

28 28 The Santikhiri community-based methadone maintenance project has attracted significant attention from national level authorities and media agencies: - In August 2013, senior representatives from the National Health Security Office (NHSO) along with a delegation of senior journalists visited the project; - In November 2013, an oral presentation was delivered at the 11 th International Congress on AIDS in Asia and the Pacific (ICAAP) at the Queen Sirikit Convention Center in Bangkok, Thailand, by a senior O-zone field worker; - In April 2014, a study visit was organized for the members of the Sub-committee on the Promotion and Protection of HIV and AIDS Rights, again drawing in several media agencies; - In August 2015, PSI Thailand published a comprehensive summary of CHAMPION-IDU results, covering innovations and best practices in harm reduction including several methadone-related interventions implemented by the O-zone team in Thailand. 6 Lessons learned and elements of success - In the early stages of project design and proposal development, community members and local authorities approved the concept of community-based methadone service delivery but were resistant to the maintenance approach in favor of a detoxification model. - After a comprehensive evaluation, results demonstrated the weaknesses of the detoxification approach and a new consensus was established in favor of methadone maintenance. - The multi-sectoral collaboration model developed to support the Santikhiri methadone maintenance project was grounded on mutual respect and consensus between O-zone project workers and people who use 6 Ngammee, V. & Tanguay, P CHAMPION-IDU - Innovations, best practices and lessons learned - Implementation of the national response to HIV among people who inject drugs in Thailand

29 29 drugs, as well as public health officers and government officials, all of whom contributed to the success and sustainability of the approach. - Throughout the project design and implementation, consensus was established when all parties involved benefited from the intervention and all parties remained mindful of win-win scenarios through open and transparent processes. In this respect, people who use drugs were treated as equal partners involved in the project. Despite differences of opinion, all stakeholders were able to maintain the consensus and move forward together. - Contributions and feedback from people who use drugs and project clients were taken very seriously and discussed extensively in order to ensure that the service offered would meet clients needs. - The support of the Chief District Officer was instrumental in mobilizing community support and approvals from relevant authorities. His contributions emphasized the needs for integration of services and collaboration across relevant sectors. - Experienced and friendly health care service providers who have empathy and show compassion for people who use drugs were critical enablers who facilitated opinion change amongst those who were most strongly opposed to the project and among community members. - O-zone workers have consistently demonstrated deep knowledge and expertise in recruiting, reaching out, supporting and retaining clients form communities of people who use and inject drugs. Workers regularly use their expertise to conduct sensitization and advocacy activities in communities before initiating new services. - The Mae Chan Hospital workers have invested their confidence, faith, and trust in the O-zone team and have provided regular technical support and training as well as oversight and guidance in order to ensure high quality services. Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

30 30 No one person or organization can solve the problem of drugs and narcotics alone. A sustainable solution should be drawn from knowledge, understanding and the contributions of all sectors, especially from civil society organizations and the community groups. Director of O-Zone Foundation - Changing attitudes of the community and authorities in regards to drug-related issues is a time-consuming process. Under the banner of the Santikhiri community-based methadone maintenance project, all stakeholders showed tolerance and respect towards one another. This operating environment allowed to stakeholders to try different approaches with the expectation of change should performance remain sub-optimal following analysis of project results. In the early stages of the project, the detoxification approach was piloted but when evaluation results were reviewed, the community had agreed to pilot a maintenance approach. - Throughout the design and implementation process, PWID s contributions were taken seriously and several stakeholders were supportive and encouraged investments to build their capacity to analyze problems, find solutions, and confidently present their suggestions. The meaningful involvement of people who use drugs in the project has also contributed to more tolerance and acceptance across the community. - The Santikhiri community-based methadone maintenance project contributed to a better local understanding of harm reduction services, approaches and objectives within the community and among authorities. Support for methadone and harm reduction interventions has grown with sustained peer-led advocacy.

31 31 - The Santikhiri community-based methadone maintenance project demonstrates that peer involvement in the design, delivery and evaluation of methadone maintenance services adds significant value. Civil society organizations can provide significant support and contribute to achieving national public health objectives. Providing health care services related to drug use and dependence is not the sole responsibility public health service providers, but rather should be shared through a collaborative approach involving people who use drugs, their families, and the community in order to achieve effectiveness and sustainability. - Providing community-based MMT is an innovative model that improves access to HIV prevention as well as other health services, and facilitates clients participation and empowerment, while improving the peace of mind and safety they need to comfortably access health care services. The O-zone Chiang Rai team is composed of one Regional Coordinator, one Drop-in Center Manager, one Administration and Finance Officer, two Field Officers, and ten Outreach Workers. Community-based Methadone Maintenance Therapy: An Evidence-based Report on Effective Treatment for Opioid Substance Users in Santikhiri Village, Thailand August 2015

32 PSI Thailand Foundation Q House Convent Building, 12A, Floor Convent Rd., Silom, Bangrak, Bangkok Tel: + (662) , Fax: + (662) Website: Ozone Foundation 218 Klong Prapa Rd., Bangsue,Bangkok Tel: +(662) Fax: +(662) With support from Thailand Foundation